implementation science in practice: finding the … · implementation science in practice: finding...
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IMPLEMENTATION SCIENCE IN PRACTICE: Finding The
Framework That Fits Workshop
Friday 4th August 2017Sydney and Newcastle
Twitter: #impsci #frameworks17
WELCOME
On behalf of our conference partners:• Hunter Cancer Research
Alliance• CONCERT TCRC• Sydney West TCRC• Translational Cancer
Research Network• Sydney Vital TCRC• Kids Cancer Alliance• Sydney Catalyst TCRC, and• The Cancer Institute NSW
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INTRODUCTIONBY PROFESSOR AFAF GIRGIS
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KEYNOTEBY PROFESSOR ELIZABETH EAKIN
RE-AIM framework & the Healthy Living after Cancer Project
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CRICOS Provider No 00025B
Elizabeth EakinProfessor and Director, Cancer Prevention
Research CentreUniversity of Queensland School of Public
HealthBrisbane
The RE-AIM Framework in the Context of
the Healthy Living after Cancer Partnership Project
CRICOS Provider No 00025B
Invited to address
My experience in developing the project
Why we chose the RE-AIM Framework
How we use it
Challenges in implementing the framework
Healthy Living after Cancer
Translating evidence into practice
Healthy Living after Cancer
NHMRC Partnership Project (2014 – 2018)
Partners: Cancer Councils NSW, VIC, SA, WA
Integrating an evidence‐based, telephone health coaching intervention for cancer survivors into the 13 11 20 Cancer Information and Support Service
Eakin EG, Hayes SC, Haas MR et al. Healthy Living after Cancer: A dissemination and implementation study, BMC Cancer, 2015; 15:992
Chief Investigators
Professor Elizabeth Eakin – University of QueenslandProfessor Sandi Hayes – Queensland University of TechnologyProfessor Marion Haas – University of Technology SydneyAssociate Professor Marina Reeves – University of QueenslandProfessor Janette Vardy – University of SydneyProfessor Frances Boyle – University of SydneyProfessor Janet Hiller – Swinburne University of TechnologyProfessor Gita Mishra – University of QueenslandAssociate Professor Michael Jefford – Peter MacCallum Cancer CentreProfessor Bogda Koczwara – Flinders University
Associate Investigators
Ms Kathy Chapman – Cancer Council New South WalesMs Sandy McKiernan – Cancer Council Western AustraliaDr Anna Boltong – Cancer Council VictoriaMs Amanda Robertson – Cancer Council South AustraliaProfessor Christobel Saunders – University of Western
AustraliaProfessor Afaf Girgis – University of New South WalesProfessor Wendy Demark-Wahnefried – University of
Alabama, USAProfessor Kerry Courneya – University of Alberta, CanadaProfessor Kathryn Schmitz – University of Pennsylvania,
USAProfessor Kate White – University of Sydney
Healthy Living after Cancer Team Members
CC Vic – Clare Sutton and Clem Byard
CC SA – Ann Branford, Polly Baldwin and Mia Bierbaum
CC WA – Rosemerry Hodgkin and Jo Daley
UQ – Erin Robson,Project Coordinator
CC NSW – Liz Hing and Indhu Subramanian
CRICOS Provider No 00025B
HLaC Program Overview
6 months of telephone health coaching
Delivered by Cancer Council nurses
Any adult (post-tx with curative intent)
Physical activity, healthy eating, weight loss
Evidence-based lifestyle guidelines
Cancer Council Australia. Position statement on nutrition and physical activity. Cancer Council Australia, 2013. http://www.cancer.org.au/policy-and-advocacy/position-statements/nutrition-and-physical-activity/.
Hayes SC, Spence RR, Galvao DA, Newton RU. Position Stand – Australian Association for Exercise and Sport Science position stand: Optimising cancer outcomes through exercise. J Sci and Med Sport. 2009;12:428-34.
World Cancer Research Fund, American Institute for Cancer Research. Food, nutrition, physical activity, and the prevention of cancer: A global perspective. Washington DC: AICR 2007. http //www aicr org/assets/docs/pdf/reports/Second Expert Report pdf
Maintain a healthy body weight
30 minutes moderate activity daily + resistance exercise 2x/wk
5 serves veg and 2 serves fruit daily
Limit (<2 drinks/day) or avoid alcohol
Healthy Living after Cancer Protocol
Self or clinician referralsNSW, VIC, SA, WA Cancer Councils
Screening & consent
Pre‐program assessment
6‐month Healthy Living after Cancer program
Post‐program assessment (6 & 12 months)
Developing HLaC
An evidence translation story…
HLaC development steps
Partner with:infrastructure to deliver telephone-based health coachingcancer survivorship mandate
Direct advocacy with Cancer Councils“Fit” with strategic objectivesBroad reach of our telephone-based intervention = big selling
point
Engaged extended network of academic and clinical collaborators
Concept development workshop (PoCoG and PC4)
NHMRC Partnership Project application
RE-AIM Framework
RE-AIM Framework
Reach - What % of target population participates?
Effectiveness - What is the intervention effect?
Adoption - What % of settings adopt the intervention?
Implementation - Is the intervention implemented as intended?
Maintenance - Is the intervention sustained over time?
Glasgow RE, Emmons KM. How can we increase translation of research into practice? Types of evidence needed, Annu Rev Public Health. 2007;28:413-433. www.re-aim.org
RE-AIM suited to implementation research
External ValidityDegree to which the results of an evaluation apply to people not in the evaluation, the broader population group (i.e. generalisabilityof findings)
Internal Validity
External Validity
Internal ValidityDegree to which an evaluation is correct for the group being evaluated - often dependent on accuratedefinition and measurement of program outcomes
Healthy Living after Cancer RE-AIM Evaluation
Single-group, pre-post study design
Process outcomes (primary)• Where do referrals come from? (reach)• Who takes part? (reach & representativeness)• Is HLaC delivered as intended?
(implementation)
Participant-reported outcomes (secondary)
• What benefit do participants achieve? (effectiveness)
• And maintain? (maintenance)
Economic analysis
Implementation Study
RE-AIM IndicatorsRE-AIM Dimension IndicatorREACH • # referrals (sources)
• Participant characteristicsEFFECTIVENESS • Weight, PA, diet, QoL…ADOPTION • # participating Cancer Councils
IMPLEMENTATION • % eligible after screening • Consent rates• # calls delivered (duration)• Completions / withdrawals• Participant & staff satisfaction• Program delivery costs
MAINTENANCE • Participant: 12-month follow-up• System-level: CCs continuing
program
RE-AIM Results
Adoption
Reach (& representativeness)
HLaC (n = 203)Type of cancer breast, prostate, bowel, lymphoma,
kidney, cervical,leukaemia, ovarian, thyroid, endometrial, BCC skin cancer, Ewings’ sarcoma, base of tongue
Gender 89% femaleAge 57 + 11 yrsBMI 29.0 + 6.0 kg/m2
Time since diagnosis 2 + 3 yrsEducation (High school or higher) 90%
Ethnicity - Caucasian 95%Regional / rural 25%
EEP1
Slide 26
EEP1 update with Lis reportElizabeth Eakin Price, 7/14/2017
Implementation
Referrals to date 700+
Eligible following screening 76%
Program Uptake (of those eligible) 90%
Median # of calls 11
Average call length 30 minutes
Program Completion 59%
Adverse Outcomes nil
Effectiveness (participant-reported outcomes)
Maintenance - PROs
Maintenance - CCs
Staff Satisfaction
Nurse survey feedbacko Application of coaching skills to other areas
o Increased knowledge of exercise and nutrition
o ‘Walking the talk’ in my own life
Participant Satisfaction
Healthy Living after Cancer“I am going really well, since starting the program I have changed my life – I have gone from doing no exercise to walking every day. I feel so much better – I have dropped a couple of pant sizes and lost 5kg and my doctor is happy.”
RE-AIM Challenges
Research in a service delivery context
My data/ your data / our data
• collaborative evaluation
• database challenges
Implementation
Nurse survey feedbacko Complexity of program protocolso Logistics – scheduling, missed callso Switching ‘hats’ (13 11 20 to HLaC)o Client psychosocial issues (eg, depression/anxiety)
Maintenance - HLaC+TxtIntervention
SMS Type FrequencyWeight self-monitoring reminders 1 per fortnight (optional)Goal check of behavioural goals Fortnightly for each goalPrompting behavioural cues Optional, maximum 4 per fortnightGoal re-set Once in weeks 6, 18
SMS dose:1 – 11 per
fortnight x 6m
Hi Jane. Its important to keep weighing yourself. Find time 2 jump on the scales & write it down in urweight tracker. Jenny
On top of things Sue? Did u eat 5 serves fruit/day this week? Text me back yes or no & let me know. Jenny
John u wanted 2 walk 10,000 steps/day this week. I know u can achieve urgoals so go for it! Jenny
Its important 2 re-set urweight goals Tim. Ur currently aiming 2 lose 2 kgs. If u have a new weight goal 4 the next 6 weeks then reply 2 let me know. Jenny
Final Thoughts on Implementation
Partnerships• Engaging from the outset and ongoing
• Capacity building for CC staff/nurses
• Cancers Councils are ideal partners– telephonic infrastructure with national reach– their own funding (service & research)– culture of evidence-based practice
Thank You!
MORNING TEA
10.20am-10.40am
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CASE-STUDY PRESENTATIONS
Picking the framework that fits –implementation research
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(ICAN)QUIT IN PREGNANCY TRIALBY A/PROFESSOR GILLIAN GOULD AND DR YAEL BAR ZEEV
University of Newcastle
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Indigenous Counselling & Nicotine (ICAN) QUIT in Pregnancy Trial
A/Prof Gillian Gould [email protected]
@GillianSGould
Dr Yael Bar‐[email protected]
@yaelbarzeev
School of Medicine and Public Health
University of Newcastle
Collaborators: Billie Bonevski, Peter O’Mara, Marilyn Clarke, Chris Oldmeadow, Alan Clough, Kristin Carson, Jennifer Reath, Michelle Bovill, Katherine Boydell, Ling Li, Maree Gruppetta, Roger Smith, Yvonne Cadet‐James, Renee Bittoun, Lou Atkin, Brett Cowling, Lisa Orcher.
Indigenous Counselling & Nicotine (ICAN) QUIT in Pregnancy Trial
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Aim: Improve health providers management of smoking in Aboriginal and Torres Strait Islander pregnant women
Multi‐component Intervention:Webinar training Educational resource package Free oral Nicotine Replacement TherapyAudit and feedback
Office [2]1
Slide 43
Office [2]1 I think have picture of the resources hereMicrosoft Office User, 7/25/2017
Behaviour Change Wheel1Overarching synthesis of behaviour intervention frameworks
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1Michie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science. 2011;6(1):1‐12.
COM‐B model
Office1
Slide 44
Office1 I think we need to include the TDF alsoMicrosoft Office User, 7/25/2017
What we did and challengesIntegrated findings from several studies with different levels of knowledge translation
Complex intervention at service, provider and patient level
Cultural aspects paramount
Community Based Participatory Approach
Iterative process can be hard to capture
Multiple challenges need addressing for Indigenous quitting during pregnancy
Provider trainingProvider training Family &
Partner smoking
Family & Partner smoking
Increase community support
Increase community support
Decrease StressorsDecrease Stressors
Build efficacy to
quit
Build efficacy to
quitMore evidence base
More evidence base
Consistent GuidelinesConsistent Guidelines
Access to Oral NRTAccess to Oral NRT
Increase provider optimism
Increase provider optimism
Improve health
messages
Improve health
messages
Systemic & Provider Approaches
Individual & Community Approaches
Stage 1: Understanding Behaviour
Step 1: Define the problem
Step 2: Select target behaviour
Step 3: Specify target behaviour
Step 4: What needs to change?
Stage 2: Identify intervention options
Step 1: Intervention functions
Step 2: Policy categories
Stage 3: Identify content and
implementation options
Step 1: Behaviour Change
Techniques
Step 2: Mode of Delivery
3 stages for intervention design with BCW (Michie et al 2014)
Measuring Success
Phase I
• Usability & appropriateness ‐ expert panel, focus groups, readability
• Making changes to resources
Phase II
• Pilot ‐ Resources in action and feasibility• Acceptability focus groups, interview, surveys, implementation log
• Refining resources, processes , implementation
Phase III
• SISTAQUIT cRCT training vs. usual care 30 services in 5 states• HP behaviour change, do women quit, does it help their babies?
FROM PARIHS WITH LOVE BY ALISON READ & DR MELANIE LOVELL
University of Technology Sydney
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FACULTY OF MEDICINE
From PARIHS with love ‐Measuring successful evidence‐based guideline implementation
Funded by the National Breast Cancer Foundation
Chief investigators: Prof Jane Phillips, Prof Meera Agar, Prof Fran Boyle, Prof Patricia Davidson, Dr Tim Luckett, Prof David
Currow, Prof Lawrence Lam, Dr Nikki McCaffrey, Prof Tim Shaw,
Lead investigator: Prof Melanie Lovell, Clinical Associate Professor USyd and Consultant Palliative Care Physician,
HammondCare
Stop Cancer PAIN TrialControl phase:• Usual care• Pain screening
Training phase:• Audit & feedback• Introduce interventions
Intervention phase:• Qstream• Patient held resource• Regular audit & feedback
Sustainability phase:• De‐identified audit
feedback on patients with pain scores of ≥ 7
Patient & Carer Measures Screening
consent
Weeks1, 2 & 4
Exit
Pain NRS * *EORTC QLQ‐C15 Pal + 5 items *heiQ *Availability of primary carer *Pain assessment and management audit
*
Carer measureCES Wk 2 &
4Medicare data *
Which framework and why• Implementation of
evidence is complex & multidimensional
• Conceptualize and evaluate with measures
• Explain and predict success (or not) at sites
• Fidelity
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• Promoting Action on Research Implementation in Health Services (PARIHS) framework
• Acknowledged the complexity of the research to practice change process:
• Evidence• Context• Facilitation
(Rycroft‐Malone, 2004)
PARIHS Framework
Challenges of implementing the framework
• Qualitative exploration • Used retrospectively• Use of low to high continuum• Clarity of definition of the sub-elements and how to
map definitions to results
How successful is PARIHS and how did we measure success?
• Fit for purpose• Barriers identified and
addressed• Shared lessons• Shaped negotiations
with future sites• Sharpened processes
THE THEORETICAL DOMAINS FRAMEWORK IMPLEMENTATION APPROACH BY DR NATALIE TAYLOR
Australian Institute of Health Innovation
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The Theoretical Domains Framework Implementation approach and hereditary cancer: Research Frameworks Workshop
Friday 4th Aug 2017
Natalie Taylor
The research project
Lynch syndrome
Hereditary condition
particularly bowel
Increases risk of cancers,
particularly bowel
Identification allows Identification allows surveillance/early intervention
Present in 50% Present in 50% first degree relatives
Potential to prevent Potential to prevent cancer for patients and their families
Guidelines: Tumour
Cancer Services
Guidelines: Tumour screening with follow up by Hereditary Cancer Services
Approx. 1:250
underdiagnosed
Approx. 1:250 people carry the LS gene but it is underdiagnosed
Over 17,000
in NSW alone
Over 17,000 people remain undiagnosed in NSW alone
Translation of the latest genomic evidence into practice is lacking…
Project aim: To improve the identification of colorectal cancer patients with a high likelihood of LS
using behaviour change theory and implementation science
Which framework and why?
Theoretical Domains Framework Implementation (TDFI) approach (Taylor et al.,2013b)
Why not just the TDF?
What else does the TDFI have to offer?Principles of implementationResourcesCost effective
Involve stakeholders
Medical directors and sharp end
staff
Identify target
behaviourAudit and discussion, process mapping
Identify barriersInfluences on Patient Safety Behaviours
Questionnaire (IPSBQ)
Confirm barriers and generate intervention strategies
Focus groups
Support staff to implement
Joint approach
Evaluate interventionRe‐auditing
Challenges implementing the framework
Implementation challenges
Theory PracticalCompliance
Testing
Accessibility
Problem complexity
System changes
Navigating the Navigating the system
Evaluating framework performanceWas the TDFI successful for…
Engaging stakeholders? 16 medical professionals, 2 consumers, senior approvals for interventions
Choosing the right target behaviour?
Detailed process maps cross matched with practice audit data identifying major gaps
Identifying key barriers? 37 (57% response rate) questionnaires and focus groups involving 19 healthcare professionals
Co‐designing theory based interventions?
16 interventions using theory driven approach; audit trail showing intuitive intervention development
Implementing interventions? 11 interventions implemented – significant delays
Achieving practice change? Pathology process changes; 0‐100% BRAF testing;
Improving rates of appropriate referrals into genetic services?
Hospital A referrals up by 10%; for B down by 4%; possibility of deferred referrals at last measurement point
Improving understanding for cancer genomics evidence translation?
Yes! We are assessing the acceptability, appropriateness, feasibility, adoption, and cost; and we demonstrated so much learning half way through that…
What next
• Cancer Australia and CINSW funding ($1.2m)• Three years• Three states• Post-doc and two PhD student scholarships• Test the TDFI approach vs implementation science
principles alone• Cost-effectiveness of implementation approaches• Process mapping
PRECEDE-PROCEED FRAMEWORK: LESSONS FROM THE RURAL PALLIATIVE CARE PROJECTBY PROFESSOR JANE PHILLIPS
University of Technology Sydney
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PRECEDE-PROCEED Framework: Lessons from the rural palliative care project
Prof Jane Phillips, RN PhDIMPACCT – Improving Palliative, Aged and Chronic Care through Clinical Research and Translation
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Context
• Part of a larger project three year project - strengthening rural palliative care partnerships
• Rapidly ageing regional community – 67,000 population (35% > 65 years, by 2031)
–Older people living in the community with progressive, life limiting illnesses and their families/carers had unmet palliative care needs;
• Applying the PRECEDE-PROCEED Model:
–Facilitated synthesis of the social assessment data–Established a link between the priority health problems and the communities’ needs –Focussed the planning process, targeted the intervention and provided the evaluation
framework
• COMMUNITY OF PRACTICE WORKSHOP, 4TH AUGUST 2017
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PRECEDE-PRCEED FRAMEWORK
IMPACCT
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Planning and evaluation:
• Identify and defined desired outcomes at the outset of the planning processfacilitates the development of specific and
measurable evaluation metrics Process (Phase 7), Impact (Phase 8), and Outcome (Phase 9) evaluation levels.
• Ranking system - classification of factors by relative importance and changeabilityconsideration of the determinants for change at individual, provider, and system levels allows for the identification, development, and implementation of tailored interventions with the greatest potential of achieving a positive impact.Improvement strategies that attend to the highest ranked predisposing, enabling, and reinforcing factors are more likely to be successful. 10, 24, 25].
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IMPORTANCE AND CHANGEABILITY Behavioural matrix to assist with developing targeting interventions
MORE IMPORTANT LESS IMPORTANT
MORE CHANGEABLE
HIGH PRIORITY LOW PRIORITY
Quadrant I Quadrant III
LESS CHANGEABLE
PRIORITY FOR INTERVENTION
NO INTERVENTION
Quadrant II Quadrant IV
Source: Green and Kreuter 1 (p.140)
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Conclusions
Since health related behaviours and activities that individuals engage in are almost always voluntary, any health intervention has to involve those whose behaviour(s) or actions you want to change.
Health is, by its very nature, a community issue. It is influenced by community attitudes, shaped by the community environment (physical, social, political, and economic), and coloured by community history.
Health is an integral part of a larger context, probably most clearly defined as quality of life, and it’s within that context that it must be considered. It is only one of many factors that make life better or worse for individuals and the community as a whole. It therefore influences, and is influenced by, much more than seems directly connected to it.
IMPACCT
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Thank [email protected]
A STEPPED WEDGE CLUSTER RANDOMISED IMPLEMENTATION TRIALBY DR BEA BROWN
NHMRC Clinical Trials Centre
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A stepped wedge cluster randomised implementation trial
Bea BrownAugust 2017
Acknowledgements: Sax Institute, NSW Agency for Clinical Innovation, Cancer Council NSW, University of Sydney, Prostate Cancer Foundation of Australia (PCFA)Funding: NHMRC partnership project: 1011474
• Australian Cancer Network Clinical Practice Guideline recommendation: Post‐ RP men with high‐risk features should be referred for consideration of ART
• 10 –20% of eligible men receive ART in Australia and other regions such as the US and Canada
CLICC Study Aim: To increase guideline recommended referral of eligible men post‐RP
An evidence gap… in practice
The PRECEDE‐PROCEED Model
Phase 1: Australian national strategy to improve prostate cancer services, thereby improving QoLand survival, identified provision of evidence‐based care for these men as a high priority
Phase 2: Evidence from 3 RCTs indicates desired outcome of improved QoL and survival can be achieved by altering clinical practice to increase referral in line with CPG recommendation
Adapted from Green L. http://www.lgreen.net/precede.htm [accessed October 2015]
Phases 3 & 4:Needs and barriers analysis
CLICC conceptual program logic model
Phases 5 & 6: Implementation and Process Evaluation
Opinion Leaders Provider Education and Printed Materials
Audit & Feedback Automated Systems
Local Clinical Leader
Urology
Network Co‐Chair
President of USANZ
CLICC Video
Full CPG
RCT papers
CLICC printed resource
Report 1
Report 2
Report 3
Report 4
Public pathology
MDT flagging
Private pathology
MDT flagging
Site 1 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Site 2 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Site 3 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Site 4 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Site 5 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Site 6 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Site 7 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Site 8 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Site 9 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Mixed methods process evaluation:• Quantitative measures of intervention elements to assess implementation,
participation and response, and context.• Qualitative exploration of participants experience of, and response to, the
intervention (predisposing, enabling and reinforcing factors) and the contextual characteristics of the nine participating study sites.
Enabling factorConsidered most
influencialintervention component
(21 of 29; 72%)
Reinforcing factorConsidered influential by nearly half (14 of 29; 48%).
Predisposing factorMixed response
Reinforcing factorMixed response
Phases 7 & 8: Impact and Outcome Evaluation
• Impact evaluation: assessment of knowledge and attitudinal outcomes through pre‐post intervention surveys
• Outcome evaluation: assessment of primary and secondary outcomes through blinded independent medical record review
THEORY-INFORMED INTERVENTION TO IMPROVE THE IMPLEMENTATION OF DIETARY GUIDELINES IN CHILDCARE SERVICESBY MEGHAN FINCH
University of Newcastle
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Theory-informed intervention to improve the implementation of dietary guidelines in childcare services.
Dr Meghan FinchHunter New England Population Health, University of Newcastle
Kirsty Seward (PhD student), Associate Professor Luke Wolfenden, Dr Sze Lin Yoong, Professor John Wiggers, Dr Rebecca Wyse
Context • Childcare key setting to improve child nutrition • Setting dietary guidelines recommend provision of food
in line with population dietary guidelines• In NSW guidelines are outlined in Caring for Children
– Children in care provided with 50% of recommended intake– Outline types and quantities of food – Focus on menu planning– Targeted at cooks and service managers
• Evidence indicates services are failing to meet their recommendations
– 20 year existence of guidelines– Supportive licensing and accreditation standards – High recognition among cooks and managers
Theoretical Domains FrameworkWhy the TDF? • Comprehensive, constructs from 33 behaviour change
theories grouped in 14 domains covering key factors that are known barriers and enablers to implementation behaviours
• Provides a systematic approach:– Understanding of the determinants of current and desired
implementation behaviours.– Identifying areas to change– Selection of strategies
• Successfully applied in the design of complex implementation interventions in clinical settings that have been effective in modifying care delivery practices
• Psychometrically evaluated measure to assess constructs
Theoretical Domains FrameworkDomain Example meaningKnowledge Do the key people know about the guidelines, do they understand their
rationale, do they have appropriate procedural knowledge?
Skills Do staff have sufficient skills, ability or training in required techniques?
Memory, attention and decision processes
Do staff forget to implement the guidelines, are there reminders in place?
Behavioural regulation What is done at a personal level to ensure implementation?
Social influences Who influences the decision to implement the guidelines?
Environmental context and resources
Are there sufficient resources to support implementation, what is missing?
Social/professional role and identity
Is implementation of the guidelines seen as typical staff’s role?
Beliefs about capabilities Are staff confident in their capacity to implement, what makes it easier or difficult?
Beliefs about consequences What are benefits or negative aspects of implementing guidelines?
Optimism Are staff optimistic that implementing guidelines will make a difference in the grand scheme?
Intentions How motivated are staff to implement the guidelines?
Motivation and goals How much of a priority is implementation compared to other competing demands ?
Reinforcement Is there any personal or external rewards for implementation?
Identifying barriers and enablers
• Limited awareness of whether menu meets guidelines, limited knowledge of food groups, serve sizes and the daily recommended serves per child to be provided while in care
Knowledge
• Lacking capability to undertake serve size calculations, modify recipes, read nutrition information panels, and use and apply the menu planning checklist.
SkillsSkills
• No formal schedule for menu reviewsBeliefs about consequencesBeliefs about
consequences
• Limited experience in setting SMART goals and action plans to enable service cooks and managers to work towards menu guideline implementation
Action planningAction
planning
• Service cooks lack of support from management and educatorsSocial/
professional role
Social/ professional
role
• Limited access to appropriate resources to assist with identifying food groups and planning a menu
Environmental context and resources
Environmental context and resources
Barriers and enablersDomainsLiterature review, interviews, observations
Recommendation for each
technique mapped to TDF
domains
Behaviour change technique TDF domains
Strategy selection
Intervention summary Domain Suggested
BCTImplementation strategy
Example
Knowledge
Information regarding behaviour, outcome
Training Information on importance of nutrition for children and the role of childcare. Review of content of Caring for children resource.
Information on food groups, discretionary foods, serve sizes and daily recommended serves per child
Resources Fact sheets on recommended serve sizes and Instructional materials and newsletters targeting key barriers
SkillsProblem solving, demonstration, Rehearsal
Training and follow-up support
Practice identifying food groups, undertaking serve size calculations and applying the Caring for Children menu planning checklist.
Action planning
Goal target specified Planning, prompts
Training Service cook and service manager set joint goals and action plans, using a goal setting template
Follow-up support
Review of goals and actions plans of each service and integrate with quality improvement plans
Beliefs about consequence
Monitoring
Feedback
Audit and feedback
Audit of menu at two time points (baseline and mid-intervention), with written and verbal menu feedback provided at each time point.
Securing executive support
Service manager signed MOU to provide feedback to the cook.
Social professional role/ identity
Social processes encouragement
Pressure,
Follow-up support and securing executive support
Facilitated discussions with managers and cooks to determine clear roles and responsibilities.
Manager discussions at team meetings re required roles of educators to support healthy menu implementation
Measuring success• Intervention implemented over 6 months and evaluated
via cluster randomised controlled trial with 45 childcare services
Menu compliance: – No change in full 2 week compliance (all food groups each day)– Significantly greater compliance for 3 out of the 6 targeted food
groups (fruit, meat, non-core food)
Child food consumption: – Significant improvements for 2 of 6 food groups (vegetables,
fruit)
TDF domains: – no significant differences between groups in cooks TDF scores
for domains targeted by intervention
Challenges• Identifying determinants
– Requires investment of time and resource– Domain specificity
• Measurement– Length of full survey - high participant burden– Sensitivity, scores were high indicating possible ceiling effect
hindering capacity to detect change – Balance between high behavioural specificity (to maximise
identification of determinants) and generalisability to enable relevance to a range of contexts
– Intervention may have exerted its effects through other pathways
• Framework for mapping determinants to strategies based on consensus
Hunter New England Population Health is a unit of the Hunter New England Local Health District.
Supported by NSW Health through the Hunter Medical Research Institute.
Developed in partnership with theUniversity of Newcastle.
AcknowledgementsEmail: [email protected] | Twitter: @Meghan_Finch
PANEL DISCUSSION
Including Q&AChaired by Dr Ben Smith
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EVALUATION SURVEY
https://tinyurl.com/y9nqcmfk
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LUNCH & NETWORKING
1.00pm-1.45pm
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